risk factors for multidrug-ressistant tuberculosis in addis ababa, ethiopia fikadu tadesse nigusso

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RISK FACTORS FOR MULTIDRUG-RESSISTANT
TUBERCULOSIS IN ADDIS ABABA, ETHIOPIA

by

FIKADU TADESSE NIGUSSO

Submitted in Accordance with the Requirements for the Degree of

MASTER IN PUBLIC HEALTH

at the

UNIVERSITY OF SOUTH AFRICA

SUPERVISOR: Dr NEGUSSIE TAFFA

November 2012

Dedication

I dedicate this study to the Almighty God, for his endless love, kindness,
wisdom and grace that always abounds all the days of my life.

My dedication goes to my Grand Mom whose values of leadership, humility
and sacrifice always remains fresh in my memory. My dedication also goes
to my Grand Dad, may Your Soul Rest in Eternal Peace Dear Grand Pa!
ACKNOWLEDGEMENTS

First of all, I wish to praise the Almighty God, the source of my strength, finance and
everything, without whom my life has no meaning. This study could not have been
completed without the superb guidance, uninterrupted support and helpful feedback from
my supervisor, Dr Negussie Taffa, despite his demanding activities. I would like to extend
my most heartfelt gratitude and appreciation to Dr Negussie.

I would also like to thank and express my deep gratitude to all of the following people and
institutions for their support:

o Mr Tesfaye Azmeraw for encouraging me throughout my study. I owe you a lot.
o UNISA Ethics Committee, UNISA Regional Learning Centre in Ethiopia, the Ethics
Committee of Addis Ababa City Administration Health Bureau, sub-City Health
Offices of Addis Ababa and the public health centres in Addis Ababa for allowing
me do this research and health care workers who were working in TB clinics.
o To all my relatives and friends for always encouraging me to pursue my study.
o Last but not least, my special thanks go to my beloved fiancé Ayantu Belay who is
always there supporting and encouraging me to complete my study.
RISK FACTORS FOR MULTI-DRUG RESISTANT
TUBERCULOSIS IN ADDIS ABABA, ETHIOPIA

STUDENT NUMBER: 4677-392-4
STUDENT: MR FT NIGUSSO
DEGREE: MASTER OF PUBLIC HEALTH
DEPARTMENT: HEALTH STUDIES, UNIVERSITY OF SOUTH AFRICA
SUPERVISOR: DR NEGUSSIE TAFFA

ABSTRACT

This quantitative, descriptive study investigated risk factors for MDR-TB in Addis Ababa,
Ethiopia. A total of 439 medical records belonging to MDR-TB and non MDR-TB patients
managed in public health centres from January 2008 to December 2011 were analysed.
Data were transcribed from each TB patient‟s medical records using a specifically
designed checklist.

The findings revealed that male gender, previous history of TB treatment, poor treatment
adherence, an outcome of failure after TB re-treatment, previous category of failure,
pulmonary involvement of TB infection and HIV infection were associated with MDR-TB.
The findings illustrate that efforts should be made to prioritise the development and
implementation of effective MDR TB screening and treatment protocols for these high risk
groups to improve treatment outcome and minimize the emergence of XDR TB.

Key Terms:
Addis Ababa, MDR-TB, TB, risk factor, HIV
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TABLE OF CONTENTS PAGE
CHAPTER 1

Orientation to the study
1.1 INTRODUCTION ......................................................................................................................................... 1
1.2 BACKGROUND TO THE PROBLEM ......................................................................................................... 1
1.3 GEOGRAPHICAL AREA ............................................................................................................................ 3
1.4 RATIONAL OF THE STUDY ....................................................................................................................... 3
1.5 STATEMENT OF THE PROBLEM ............................................................................................................. 3
1.6 AIM OF THE STUDY ................................................................................................................................... 4
1.6.1 Research objectives ............................................................................................................................... 4
1.7 SIGNIFICANCE OF THE STUDY ............................................................................................................... 5
1.8 FOUNDATIONS OF THE STUDY ............................................................................................................... 5
1.8.1 Conceptual framework of the study ..................................................................................................... 5
1.9 RESEARCH DESIGN AND METHODOLOGY ........................................................................................... 6
1.9.1 Research design ..................................................................................................................................... 6
1.9.2 Population ............................................................................................................................................... 6
1.9.3 Sample and Sampling ............................................................................................................................ 6
1.9.4 Data collection instrument .................................................................................................................... 7
1.9.5 Data analysis ........................................................................................................................................... 8
1.10. VALIDITY AND RELIABILITY ................................................................................................................. 8
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1.10.1 Validity ................................................................................................................................................... 8
1.10.2 Reliability ............................................................................................................................................... 8
1.11 ETHICAL CONSIDERATIONS ................................................................................................................. 9
1.12 DEFINITIONS OF KEY CONCEPTS ........................................................................................................ 9
1.13 SCOPE AND LIMITATIONS OF THE STUDY ........................................................................................ 10
1.14 OUTLINE OF THE STUDY ..................................................................................................................... 11
1.15 CONCLUSION ......................................................................................................................................... 11
CHAPTER 2
Literature review
2.1 INTRODUCTION ....................................................................................................................................... 12
2.2 GLOBAL EPIDEMIOLOGY OF MDR-TB ................................................................................................. 12
2.3 EPIDEMIOLOGY OF MDR-TB IN ETHIOPIA ........................................................................................... 13
2.4 HEALTH CARE SYSTEM OF ETHIOPIA IN RELATION TO TB ............................................................. 14
2.5 TB PREVENTION AND CONTROL PROGRAM IN ETHIOPIA ............................................................... 15
2.5.1 MDR-TB Prevention and Control in Ethiopia ..................................................................................... 16
2.6 MDR-TB TREATMENT STRATEGIES IN ETHIOPIA .............................................................................. 17
2.7 RISK FACTORS FOR MDR-TB ................................................................................................................ 19
2.7.1 Previous history of tuberculosis treatment ....................................................................................... 19
2.7.1.1 Types of previous TB treatment category ...................................................................................... 20
2.7.1.2 Previous TB treatment outcome ...................................................................................................... 20
2.7.2. TB/HIV Co-infection ............................................................................................................................. 21
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2.7.3 Age and MDR-TB .................................................................................................................................. 22
2.7.4 Sex and MDR-TB ................................................................................................................................... 23
2.7.5 Poor TB Treatment Adherence ............................................................................................................ 24
2.7.6 Site of TB Involvement ......................................................................................................................... 24
CHAPTER 3
Research Design and Methodology
3.1 INTRODUCTION ....................................................................................................................................... 25
3.2 STUDY DESIGN ........................................................................................................................................ 25
3.2.1 Quantitative ........................................................................................................................................... 26
3.2.2 Descriptive study .................................................................................................................................. 26
3.2.3 Cross-sectional Research Design ...................................................................................................... 26
3.2.4 Comparative studies ............................................................................................................................ 27
3.3. SAMPLING ............................................................................................................................................... 27
3.4 STUDY POPULATION .............................................................................................................................. 28
3.4.1 Inclusion criteria ................................................................................................................................... 28
3.4.2 Exclusion criteria .................................................................................................................................. 29
3.5 SAMPLE SIZE ........................................................................................................................................... 29
3.6 RESEARCH SETTING .............................................................................................................................. 30
3.7 DATA COLLECTION ................................................................................................................................ 30
3.7.1 Research instrument ............................................................................................................................ 30
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3.8 DATA ANALYSIS ...................................................................................................................................... 31
3.9 VALIDITY AND RELIABILITY .................................................................................................................. 31
3.9.1 Validity of research instrument ........................................................................................................... 32
3.9.2 Reliability of research instrument ....................................................................................................... 32
3.10 ETHICAL CONSIDERATIONS ............................................................................................................... 33
3.10.1 Protection of human rights: .............................................................................................................. 33
3.10.2 Informed consent: .............................................................................................................................. 33
3.10.3 Autonomy: ........................................................................................................................................... 34
3.10.4 Confidentiality and anonymity: ......................................................................................................... 34
3.10.5 Beneficence: ....................................................................................................................................... 34
3.10.6 Justice: ................................................................................................................................................ 34
3.10.7 Rights of institutions where the research is based: ....................................................................... 35
3.10.8 Scientific integrity on the part of the researcher: ........................................................................... 35
3.11 CONCLUSION ......................................................................................................................................... 35
CHAPTER 4
Analysis and discussion of the research findings
4.1 INTRODUCTION ....................................................................................................................................... 36
4.3 DATA MANAGEMENT AND ANALYSIS ................................................................................................. 36
4.4 RESEARCH RESULTS ............................................................................................................................. 37
4.4.1 Socio-demographic characteristics.................................................................................................... 37
4.4.1.1: Sex distribution ................................................................................................................................ 38
4.4.1.2: Age distribution ................................................................................................................................ 38
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4.4.1.3: Geographical location of residence ............................................................................................... 38
4.4.2: TB treatment adherence status .......................................................................................................... 38
4.4.2.1: Missed a dose of anti-TB drugs during intensive phase of previous treatment ....................... 38
4.4.2.2: Previous TB treatment adherence status of the patient .............................................................. 39
4.4.3: TB treatment status, category and outcome .................................................................................... 39
4.4.3.1: Previous history of TB treatment.................................................................................................... 39
4.4.3.2: Previous category of TB treatment................................................................................................. 40
4.4.3.3: Number of times treated for TB ...................................................................................................... 41
4.4.3.4: Previous TB treatment outcome ..................................................................................................... 41
4.4.3.5: Site of TB involvement ..................................................................................................................... 42
4.4.3.6: Result of Acid Fast Bacilli (AFB) smear ......................................................................................... 43
4.4.4: HIV status of the MDR-TB and non MDR-TB patients ...................................................................... 43
4.4.4.1: TB/HIV co-infection .......................................................................................................................... 44
4.5 CONCLUSION ........................................................................................................................................... 45
CHAPTER 5
Conclusions, limitations and Recommendations
5.1 INTRODUCTION ....................................................................................................................................... 46
5.2 RESEARCH DESIGN AND METHODOLOGY ......................................................................................... 46
5.3 SUMMARY AND INTERPRETATION OF THE RESEARCH FINDINGS ................................................. 47
5.3.1: To determine the socio-demographic factors associated with the risk of MDR-TB .................... 47
5.3.1.1: Socio-demographic factors of MDR-TB and non MDR-TB patients ............................................ 47
5.3.1.1.1: Gender as a risk factor for MDR-TB ................................................................................................ 47
5.3.1.1.2: Age as a risk factor for MDR-TB...................................................................................................... 47
5.3.1.1.3: Role of geographical location of patients in relation to health facilities ........................................... 48
5.3.2: To determine if non adherence to treatment is associated with development MDR-TB ............. 48
5.3.2.1: TB treatment adherence status ....................................................................................................... 48
5.3.3: To determine the types of TB treatment categories and outcomes associated with MDR-TB ... 49
5.3.3.1: Previous history of TB treatment.................................................................................................... 49
5.3.3.2: Previous category of TB treatment................................................................................................. 49
5.3.3.3: Number of times treated for TB ...................................................................................................... 49
5.3.3.4: Previous TB treatment outcome ..................................................................................................... 50
5.3.3.5: Site of TB involvement ..................................................................................................................... 50